a greater accuracy in the enumeration, or to enlarged and improved institutional facilities for the care of the insane, which always tend to an increased use of hospitals by persons who are not compelled to seek public aid. The weight of authoritative opinion appears to support the view of an actual increase in insanity. At all events the ratios of the insane, whether measured solely by the number in hospitals or with the addition of those found outside of institutions, have increased during recent years in all countries for which reliable returns are at hand. ** * The returns for England and Wales are of all "notified lunatics." The figures for Ireland do not include the insane in private dwellings except a few single chancery cases. In the number shown for Scotland are counted "inmates of training schools and the lunatic department of the general prison." The 12,819 insane in Canadian hospitals represent the total treated during the year in public hospitals. The number present on a given date would necessarily be smaller and show a more favorable ratio. The statistics for France are of inmates of public and private asylums. There has been no official enumeration of the insane in the German Empire since 1871. The figures given were compiled by Dr. Max Hackl; they are based upon hospital returns and are considered authoritative, though rather conservative. There has been no general census of the insane in Italy since 1871. In that year the total number of insane persons returned for continental and insular Italy was 44,102. The figures given in the table were compiled by Doctors Tamburini and Fornasari di Verce in "Rivista Sperimentale di Freniatria," 1900. Of the total number of known insane in Austria January 1, 1901, 46.7 per cent were in asylums, 11.8 per cent were sheltered in other eleemosynary institutions, and 41.5 per cent were in private care. In Hungary also but a small fraction of the insane were provided for in public institutions. The figures for the Netherlands and Switzerland include inmates of public and private asylums. The striking difference between Norway and Sweden in regard to ratios of the total number of insane appears to be due to the fact that the total given for Norway (5,397) was obtained by an actual enumeration, while the total for Sweden (8,093) represents only the number inspected by the authorities whose duty it is to visit known insane persons in their homes. In the year 1903 admissions to the public hospitals of Sweden had to be denied for lack of space in 1,698 cases. There are certain discrepancies between the ratios of insanity for foreign countries, as set forth in the table, and the relative ranking of the natives of these countries in the United States in the matter of insanity. This is made evident by a comparison of the list of immigrant nationalities, ranked in the order of relative liability to insanity, given in the census report and already quoted, and a similar list showing the different foreign countries in descending order of their ratios of insanity computed upon the basis of insane persons reported in hospitals. These lists are as follows: Racial or national tendencies, in the United States and abroad, are discussed as follows in the census report: " It is primarily the business of the alienist to trace the relation between the classification of the immigrant races and the probable causes that make some of them seem so much more liable to insanity than others. It is generally held that the nationalities showing the least liability to insanity are also among the most primitive in point of education and standard of living. Given comparative freedom from vice and comparative virility of stock, so the argument runs, and it will be seen that the mental equilibrium is more frequently upset in the instance of the highly organized nationalities; that is, they show less ability to withstand the shocks of a new environment, the pressure of unwonted economic conditions, etc., than the nationalities lower in the social scale. It is further asserted that an increase of insanity is a concomitant of present-day civilization, and that when the disease appears to be alarmingly prevalent in a nationality which as a whole has not reached a very high level there will usually be found in such a nationality the taint of a common vice. The facts brought out in the present investigation in regard to the comparative liability to insanity of the immigrants hardly suffice for a confirmation of the above views. The matter is one that must be studied in the light of the statistics of the insane for the countries whence the nationalities in question come. In the case of the English and Welsh, for instance, it was shown that they stand seventh among the foreign nationalities in the United States with regard to the relative number of insane they contributed to the insane population in hospitals in 1903. Yet the number of insane per 100,000 of population in England and Wales is very much larger than the corresponding number for the United States. England and Wales also show much larger ratios of insane than Germany or the Scandinavian peninsula. According to the classification made of the immigrants with respect to their liability to insanity, the Canadians show the least liability to this disease. Nevertheless, the ratio of the insane in Canada, whether only the number in hospitals or the total for the country be considered, exceeds the ratio for the United States, and is higher than the ratios for the Scandinavian countries and Germany. Yet the Scandinavians and Germans contribute relatively larger numbers to the insane population of this country. * * * The statistics of the insane for the countries from which most of the recent immigrants came are lacking or are too meager for purposes of comparison. The comparatively primitive condition of some of these peoples may perhaps for the present render them less liable to insanity than others. At least this appears to be true of the immigrants from eastern and southern Europe. The differences beween the ranking of the several countries and the ranking of the corresponding nativities in the United States may be attributed to several causes. They are doubtless due, in part, to the variation in the classification of countries and nativities, and in the degree of completeness of the data upon which the insanity ratios are based. THE EFFECTS OF CHANGE OF ENVIRONMENT. It should be remembered that the aliens who have immigrated to the United States, being drawn, in many instances, from the less favored social or industrial classes in the countries from which they come, may not be in a general sense representative of the entire population of these countries. The effect of a change of environment upon the individual immigrant may also be in some cases the occasion of insanity. These subjects are referred to in the census report, as follows: This rather striking discrepancy between the comparatively slight liability to insanity exhibited by some nationalities among the immigrants and the known large ratios of the insane in their home countries can hardly be due to the fact that some of them are represented in the United States by the best of their stock while others send a U. S. Census, Special Report, "Insane and feeble-minded in hospitals and institutions 1904," pp. 27 and 28. over the least fit. It is significant that insanity is apparently most prevalent in the nationalities who were among the earliest immigrants to this country and contributed the sturdiest of their people. It may therefore be that an explanation of these dis crepancies is that conditions of American life are conducive to an increase in insanity. In the foregoing pages national tendencies and changes of environment have been discussed only in their relation to insanity. The probable effect of these factors upon feeble-mindedness and kindred mental defects among the immigrants is not dealt with in the census report. As the data pertaining to the feeble-minded are not comprehensive, nor even representative, a statistical presentation of the subject would be of doubtful value and any attempted deductions might well be misleading. SUMMARY. The situation with respect to insanity among immigrants, as indicated by the data and authorities upon which this report is based, may be summarized as follows: Although the immigration of mentally unsound aliens is prohibited by law, and although many mentally diseased or defective aliens are turned back at the ports of entry, there are in the United States many thousands of insane or feeble-minded persons of foreign birth. It appears that insanity is relatively more prevalent among the foreign-born than among the native-born, and relatively more prevalent among certain immigrant races or nationalities? than among others. In general, the nationalities furthest advanced in civilization show, in the United States, a higher proportion of insane than do the more backward races. For the high ratio of insanity among the foreign-born, several causes have been assigned, and while it is difficult to determine the values of the various factors it is prob-ably true that racial traits or tendencies have a more or less important influence. A further cause of mental disease is probably to be found in the total change in climate, occupation, and habits of life which the majority of immigrants experience after arrival in the United States. The provisions of the immigration law of 1907 for the exclusion of mentally unsound persons are seemingly complete and comprehensive, while the enforcement of such provisions is doubtless as satisfactory as can be expected in view of conditions under which arriving immigrants must be inspected. a See Vol. II, p. 732. |